Experts look again at statins in diabetes

Exclusive: Cardiovascular experts are considering controversial proposals that GPs should scale back on their use of statins in patients with diabetes, as they draw up new guidance for the profession due in the new year.

The Joint British Societies guidelines are currently being updated and advisers are looking at whether diabetes should be downgraded from its current status as a ‘cardiovascular disease equivalent'.

The move would be seen as a shift away from some aspects of primary prevention of cardiovascular disease, with the advisory panel also set to pre-empt NICE by downgrading use of aspirin in patients without prior events.

A series of recent studies have questioned the benefits for use of statins and aspirin in primary prevention.

Both NICE and JBS2 guidelines recommend routine use of statins in patients with type 2 diabetes aged over 40 years, and in younger patients with other risk factors.

The JBS panel is considering whether this age requirement should be scrapped – with the onus placed on overall risk instead - or increased to 50 years.

As Pulse has previously revealed, JBS experts are considering a number of other radical changes to the guidance, including a switch to calculating CVD risk over a lifetime rather than over 10 years, and are likely to recommend earlier use of antihypertensive combinations.

Professor Richard Hobbs, head of primary care and general practice at the University of Birmingham and the Primary Care Cardiovascular Society's representative on the JBS3 panel, said the JBS3 panel was looking at diabetes closely.

Speaking at the annual PCCS meeting in Leeds this week, Professor Hobbs, a GP in Birmingham, cautioned that not all epidemiological data supported routine prescribing of statins in patients with diabetes: ‘Diabetes in isolation does not confer excess risk. There is a multiplier effect if patients survive with risk factors long enough, but not all those with diabetes have a metabolic risk profile.'

Professor Hobbs said the panel was considering increasing the age patients were considered for statin treatment or eliminating age altogether and recommending use of a risk score including diabetes in these patients, such as QRISK. ‘There is going to be a debate over this,' he warned.

Professor Hobbs added it was ‘unlikely' the recommendation of aspirin for primary prevention of cardiovascular disease would be renewed: ‘Aspirin has probably had its day. It's a bit like digoxin in heart failure dropping down the pecking order.'

Dr Kathryn Griffiths, president of the PCCS, said: ‘The original evidence for this is quite old now, and these people are being managed better now in terms of their hypertension, their lipids and hopefully their diabetes as well.

'This means that they are thought to be at an intermediate risk in relation to the diabetes, rather than it being a CV risk equivalent, but we will have to see what the guidelines group's review of the evidence brings.'